On December 20, 2016, the Centers for Medicare & Medicaid Services (CMS) finalized regulations regarding the Surgical Hip and Femur Fracture Treatment (SHFFT) model in the Advancing Care Coordination through Episode Payment Models final rule.
This final rule implements a new payment model for Part A and B items and services provided to Medicare fee-for-service beneficiaries under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective bundled payments for items and services that are related to SHFFT and recovery, beginning with a hospitalization for SHFFT and extending for 90 days following hospital discharge.
Proposed Rule: Cancellation of Advancing Care Coordination through Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR)
This proposed rule proposes to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to rescind the regulations governing these models. It also proposes to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model, including: giving certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model; technical refinements and clarifications for certain payment, reconciliation and quality provisions; and a change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track. Comments on this proposed rule must be received at one of the addresses provided in the proposed rule no later than 11:59 p.m. EST on October 15, 2017. The proposed rule is now available.
The SHFFT Model holds participant hospitals financially accountable for the quality and cost of a SHFFT Model episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers. A SHFFT episode is defined by the admission of an eligible Medicare fee-for-service beneficiary to a hospital paid under the Inpatient Prospective Payment System (IPPS) that eventually results in a discharge paid under the following Medicare Severity-Disease Related Group (MS-DRG):
- MS-DRG 480 (Hip and femur procedures except major joint with major complication or comorbidity - CC),
- MS-DRG 481 (Hip and femur procedures except major joint with complication or comorbidity - MCC), or
- MS-DRG 482 (Hip and femur procedures except major joint without CC or MCC).
The first performance period will begin on July 1, 2017 and will continue for five performance years, ending on or about December 31, 2021.
The SHFFT Model will be implemented in 67 geographic areas, defined by metropolitan statistical areas (MSAs). MSAs are counties associated with a core urban area that has a population of at least 50,000. Non-MSA counties (no urban core area or urban core area of less than 50,000 population) were not eligible for selection. Eligible MSAs, which were used for MSA selection in the CJR Model, must have had at least 400 eligible (not included in the BPCI initiative) CJR cases between July 2013 and June 2014, and no more than 50 percent of otherwise qualifying CJR procedures occurring in a Maryland hospital, hospital participating in BPCI, or receiving post-acute care services at a skilled nursing facility (SNF) or home health agency (HHA) participating in BPCI. The 67 geographic MSAs participating in the SHFFT Model are the same 67 MSAs that are currently participating in the CJR Model. The MSAs were selected by stratified random sampling for CJR. The 67 MSAs selected are listed below:
As of December 20, 2016, approximately 865 hospitals will participate in the SHFFT model.
The episode of care continues for 90 days following discharge. Part A and Part B services related to the SHFFT Model episode are included in the episode. For each performance year of this model, CMS will set Medicare episode quality-adjusted target prices for each participant hospital that include payment for all related services furnished to eligible Medicare fee-for-service beneficiaries who have SHFFT surgery at that hospital. Quality-adjusted target prices will initially be set based on a blend of provider-specific and census-region historical claims data for beneficiaries hospitalized for SHFFT, and gradually transition to being set based on census-region pricing only. All providers and suppliers will continue to be paid under the usual payment system rules and procedures of the Medicare program for episode services throughout the year. Following the end of a model performance year, actual spending for the episode (total expenditures for related services under Medicare Parts A and B) will be compared to the Medicare quality-adjusted target price for the participant hospital where the beneficiary had the SHFFT surgery. Depending on the participant hospital’s quality and episode spending performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending.
Quality and the Pay-for-Performance Methodology
The SHFFT Model has the potential to improve quality in four ways. First, the Model adopts a quality first principle where hospitals must achieve a minimum level of episode quality before receiving reconciliation payments when episode spending is below the target price. Second, higher episode quality, considering both performance and improvement, may lead a hospital to receive quality incentive payments based on the hospital’s composite quality score, a summary score reflecting hospital performance and improvement on the following two measures:
- Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) measure (NQF#1550); and
- Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF#0166).
The composite quality score also takes into consideration a hospital’s submission of THA/TKA patient-reported outcomes and limited risk variable voluntary data.
Third, in addition to quality performance requirements, the Model incentivizes hospitals to avoid expensive and harmful events, which increase episode spending and reduce the opportunity for reconciliation payments.
Fourth, CMS provides additional tools to improve the effectiveness of care coordination by participant hospitals in selected MSAs. These tools include: 1) providing hospitals with relevant spending and utilization data; 2) waiving certain Medicare requirements to encourage flexibility in the delivery of care; and 3) facilitating the sharing of best practices between participant hospitals through a learning and diffusion program.
Beneficiary Benefits and Protections
Beneficiaries retain their freedom of choice to choose services and providers. Physicians and hospitals are expected to continue to meet current standards required by the Medicare program. All existing safeguards to protect beneficiaries and patients remain in place. If a beneficiary believes that his or her care is adversely affected, he or she should call 1-800- MEDICARE or contact their his or her state’s Quality Improvement Organization by going to http://www.qioprogram.org/contact-zones. The establishment of an Alternative Payment Models Beneficiary Ombudsman will also ensure monitoring of the models and fielding inquiries from beneficiaries if needed. The final rule also describes additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services.
- SHFFT Provider and Technical Fact Sheet (PDF)
- Final Rule
- Final Rule Press Release
- Proposed Rule
- Proposed Rule Fact Sheet
- Proposed Rule Press Release
- SHFFT Provider List (ZIP)
- SHFFT Model Parameters (ZIP) – contains episode initiating MS-DRGs, excluded readmission MS-DRGs, and other exclusions from model